Family Therapy With Patients Having Physical Health Problems

Medical family therapy is a biopsychosocial systems approach to psychotherapy with patients and families experiencing a physical illness, trauma, or disability. (The term medical pertains here to having to do with health and illness rather than "concerning physicians" as it is defined in some dictionaries.) This therapy assumes that no biomedical event occurs without psychosocial background and repercussions, and no psychosocial event occurs without some biological features.

In the practice of medical family therapy, close attention is paid to the role that medical illness plays in the emotional life of the patient and in the interpersonal dynamics of the family system. Collaboration between psychologists and other health care providers is a centerpiece of the approach.

Medical family therapy can be brief, focusing, for example, on an acute reaction to a physical problem. However, an illness can bring to the surface years, or even generations, of conflict, leading to more extensive treatment.

Physical illness tends to bring to the fore issues that may hide beneath the surface of, for example, a marital problem or a depression: beliefs about life—the uncertainty about why we are here, what we can and cannot control, and what will happen tomorrow—and beliefs about death—its form and its meaning.

Medical family therapy must deal, therefore, with existential issues such as how people give meaning to their lives and their suffering, how they wish to live given certain limitations, how they want to love and be loved for the remainder of their lives, and how they will make peace with themselves. For the family, serious illness can evoke emotional responses similar to those precipitated by an actual death, sending a shock wave of threatened loss that shakes the foundation of the system and rattles relationships in unpredictable ways.

Specific objectives of medical family therapy include enhanced day-to-day functioning for the patient and family, improved coping with chronic and acute symptoms, decreased conflict about treatment (e.g., managing medication), improved communication with health care providers, increased acceptance of a health problem that cannot be cured, and increased ability to make necessary lifestyle changes, such as diet or exercise. Techniques that often are helpful include eliciting the family illness history and meaning, respecting defenses, removing blame and accepting "unacceptable" feelings, reinforcing family rituals and other aspects of family identity that are not part of the illness, using family strengths and resources, and providing psychoeducation and support.

The overarching goals of medical family therapy are to promote agency and communion among family members. Increasing agency means increasing a patient's and family's sense of effectiveness in managing the illness and other aspects of their lives. Communion refers to the need to attend to the communication and emotional bonds that can be frayed by the challenges of pain and illness. Together, agency and communion refer to individual autonomy within a relational context.

Activating agency depends on one's orientation to the patient and on what questions are asked. Frequently asked questions include the following:

• What do you think caused your problem?

• Why do you think it started when it did?

• What kind of treatment should you receive?

• Should we expect complications?

• Has anyone else in your family faced an illness similar to this?

• What might make healing now a struggle for you?

• Do you see yourself as having much to live for?

 
Activating agency includes understanding the meaning patients attribute to an accident or illness and helping them to negotiate a mutually agreeable treatment plan with their healthcare provider.

Enhancing communion involves decreasing social isolation, which has significant health consequences both in terms of onset of disease and in terms of its treatment. For example, some research shows that lack of social support is a stronger risk factor for illness than cigarette smoking.

Serious illness or disability provides opportunities for communicating, for resolving old conflicts, and for forging new levels of healthy family bonding. Questions that help activate communion include the following:

• Who in the family can be counted on to provide physical assistance or emotional support?

• Who is typically left out of decision making when the family is in crisis?

• How can that person be engaged now?

• Is the family willing to participate in a psychoeducational family group?

 
Medical family therapy allows clinicians to avoid the traps of "somatic fixation" or "psychosocial fixation" that reduce a complex problem to either its physical or its emotional components exclusively. Although this Cartesian mind–body split still dominates Western culture, biopsychosocial theory reaches toward an integration consistent with the tenets of systems theory. Medical family therapy is a psychotherapy that has emerged from this integration and can also be thought of as a "metaframework" through which can be woven specific approaches to psychotherapy, such as family systems, psychodynamic, and cognitive–behavioral therapy.

Dr. McDaniel identifies her approach as "medical family therapy." What does this imply to you? To be more specific, what do you expect of her? Will Dr. McDaniel be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?

Susan H. McDaniel, PhD, is professor of psychiatry (psychology) and family medicine at the University of Rochester School of Medicine and Dentistry in Rochester, New York, where she is director of the Division of Family Programs in Psychiatry and codirector of Psychosocial Programs in Family Medicine.

Dr. McDaniel received her doctorate in clinical psychology from the University of North Carolina at Chapel Hill and completed an internship at the University of Texas Medical Branch in Galveston, Texas, and a postdoctoral fellowship in family therapy at the Texas Research Institute for Mental Sciences in Houston, Texas.

Dr. McDaniel's career has focused on teaching, research, and developing clinical approaches for psychologists, family therapists, and physicians in the area of families and health.

She is the author of six books, including Medical Family Therapy: A Biopsychosocial Approach for Families With Health Problems (with Jeri Hepworth and William Doherty, 1992), Integrating Family Therapy: A Handbook of Family Psychology and Systems Theory (with Richard Mikesell and Don-David Lusterman, 1995), and The Shared Experience of Illness: Stories of Patients, Families, and Therapists (with Jeri Hepworth and William Doherty, in press). Dr. McDaniel is also coeditor of the journal Families, Systems & Health.

Since 1986, she has been an active member of the board of Division 43 (Family Psychology) of the American Psychological Association. In 1995, she was named Family Psychologist of the Year by Division 43.

• Kirschenbaum, H., & Henderson, V. L. (Eds.). (1989). The Carl Rogers reader. Boston: Houghton Mifflin.
• Lietaer, G., Rombauts, J., & Van Balen, R. (Eds.). (1990). Client-centered and experiential psychotherapy in the nineties. Leuven, Belgium: Leuven University Press.
• Raskin, N. J. (1978). Becoming—a therapist, a person, a partner, a parent, a ... . Psychotherapy: Theory, Research and Practice, 15, 362–370.
• Raskin, N. J., & Rogers, C. R. (1989). Person-centered therapy. In R. J. Corsini & Wedding, D. (Eds.), Current psychotherapies (4th ed., pp. 155–194). Itasca, IL: F. E. Peacock.
• Rogers , C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin.
• Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships, as developed in the client-centered framework. In S. Koch (Ed.), Psychology: The study of a science (Vol. 3, pp. 184–256). New York: McGraw Hill.
• Rogers, C. R. (1961). On becoming a person. Boston: Houghton Mifflin.
• Zimring, F. M., & Raskin, N. J. (1992). Carl Rogers and client/person-centered therapy. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change (pp. 629–656). Washington, DC: American Psychological Association.

APA Videos

• Chronic Illness
  Len Sperry
• Constructivist Therapy
  Robert A. Neimeyer
• Counseling Clients Who Have Difficulty Getting Pregnant Again
  Susan H. McDaniel
• Counseling Clients Who Have Trouble Conceiving
  Susan H. McDaniel
• Couples and Illness
  Tamara Goldman Sher
• Family Therapy Over Time
  Susan H. McDaniel 
• Functional Family Therapy
  James F. Alexander
• Individual Therapy From a Family Systems Perspective
  Florence W. Kaslow
• Pain Management
  Robert J. Gatchel
• Parenting Our Elderly Parents
  Patricia J. Pitta

APA Books

• Casebook for Integrating Family Therapy: An Ecosystemic Approach
  Edited by Susan H. McDaniel, Don-David Lusterman, and Carol L. Philpot
• Chronic Depression: Interpersonal Sources, Therapeutic Solutions
  Jeremy W. Pettit and Thomas E. Joiner
• Emotion-Focused Therapy for Depression
  Leslie S. Greenberg and Jeanne C. Watson
• Feminist Family Therapy: Empowerment in Social Context
  Edited by Louise B. Silverstein and Thelma Jean Goodrich
• Integrating Family Therapy: Handbook of Family Psychology and Systems Theory
  Edited by Richard H. Mikesell, Don-David Lusterman, and Susan H. McDaniel
• Interpersonal Psychotherapy for Depressed Older Adults
  Gregory A. Hinrichsen and Kathleen F. Clougherty
• Understanding Depression in Women: Applying Empirical Research to Practice and Policy
  Edited by Carolyn M. Mazure and Gwendolyn Puryear Keita